Chest Injury Guidelines Contents: 1-3 Chest injury management Appendix 1 – Simple thoracosotomy without drain insertion Appendix 2 – Thoracotomy Appendix 3 – Evaluation of Pneumofix needle decompression device by CCPs Appendix 4 – The use of ultrasound devices Appendix 5 - Competency based process for autonomous finger thoracostomy WMAS Clinical Guidelines CG-CLI-009 I Version - 1 Guideline ID CG-CLI-009 Version Version 2 Title Chest Injury Approved by Immediate Care Governance Group Date Issued May 2017 Review Date March 2019 Directorate Immediate Care Governance Group Emergency Care Assistant Consultant paramedics X Authorised Staff Technician HEMS CCPs X For main Advanced Technician X Advanced practitioner X guideline approved by ICGG Student Paramedic X Doctor X Paramedic X Green – Deviation permissible for registered healthcare professionals Clinical Category with application of clinical judgement 1. Scope 1.1. These guidelines are written to support clinicians’ management of patients with chest injuries whilst being treated by West Midlands Ambulance Service NHS Foundation Trust responders. 2. Background 2.1. Chest injuries are significant contributors to major morbidity and mortality. Assessment of thoracic conditions is often difficult within the Prehospital environment and patients may not display classical signs of injury which may delay timely management. 3. Guidelines 3.1. Assessment 3.1.1. In accordance with JRCALC Guidelines; Thoracic Trauma, Trauma Emergencies 3.1.2. The following signs must be actively assessed and/or excluded: Respiratory rate & pattern Presence of penetrating chest wound, bruising Asymmetrical chest expansion; flail chest, relative hyperexpansion, splinting – May not be seen with bilateral tension pneumothoraces or other chest injuries Neck wounds, surgical emphysema, swelling, laryngeal crepitus Venous engorgement - may not be evident with hypovolaemia / neck collar in-situ Haemoptysis – Indicating tracheobronchial injury / lung contusion / Max-Fax injury Chest wall swelling Chest wall crepitus Chest wall tenderness Tracheal deviation (late sign of tension pneumothorax if at all present!) Cardiovascular compromise 3.1.3. It is important to attempt full examination of the chest (including back, sides, axillae and shoulders) to avoid missing posterior or lateral injuries. Avoid prolonged exposure for patient dignity and avoidance of cooling. 3.1.4. Strongly consider chest percussion and auscultation where ambient noise permits. The lateral chest and anterior armpit should be auscultated to avoid transmitted sounds from the contralateral chest. 3.1.5. Consider the assessment of injury and symptoms described in the context of the mechanism of injury. 3.2. Minimum Recordings for PRF in Chest Trauma Respiratory rate Radial Pulse Conscious level; (GCS) Pulse oximetry ECG Monitoring Blood Pressure Capnography (if LMA/ETT in situ) 3.3. Paediatrics 3.3.1 Rib fractures indicate a significant mechanism of injury and serious injury should be suspected. Isolated chest injury is rare. 3.3.2 Chest drain insertion is rarely indicated prehospital, requires special expertise and equipment and the need would generally suggest immediate departure to a paediatric trauma centre. 3.4 Interventions 3.4.1 All patients with evidence of thoracic injury require high flow oxygen through a non re-breathe mask (15L/min) 3.4.2 Adequate analgesia 3.4.3 The majority of patients can be adequately managed with the above measures with timely transfer to hospital. 3.5 Splinting / Positioning 3.5.1 The ideal position for managing chest injuries is in a sitting position. However, the need to simultaneously manage the cervical spine may preclude this position and result in respiratory embarrassment when laid supine. Assessment of the severity of the injury and the need to assist ventilation may mandate the need for rapid sequence induction and assisted ventilation prior to transfer in the supine, fully spinal immobilised position. 3.5.2 Splinting a flail segment options may include: Direct pressure applied by hand 500ml bag of fluid taped over the flail segment Lie the patient with the flail segment downwards 3.6 Chest Seal 3.6.1 Indications Open pneumothorax 3.6.2 Advantages Quick 3.6.3 Disadvantages Lack of adhesion to surrounding skin Does not re - expand collapsed lung Latex components No collection of blood if accompanied by haemothorax 3.6.4 Technique 3.6.4.1 Skin may need to be dried & shaved to facilitate adequate adhesion 3.6.4.2 An adhesive dressing with a central hole placed over the wound with a chest seal placed over it is an alternative 3.7 Needle Thoracocentesis (Needle Chest Decompression) 3.7.1 Tension pneumothorax is a rare prehospital event in blunt trauma. There is extensive evidence that tension pneumothorax presents differently dependent on whether the patient is spontaneously breathing or is intubated & ventilated. Positive pressure ventilation increases the risk of tension pneumothorax substantially. 3.7.2 Indications Suspicion of a compromising pneumothorax in a ventilated patient Worsening respiratory distress in a trapped patient breathing spontaneously with symptoms consistent with a tension pneumothorax 3.7.3 Advantages Quick Potential resolution of obstructive shock 3.7.4 Disadvantages High failure rate (immediately or soon after intervention) o Cannula rapidly tracks back out of pleural space and ceases to function o A number of people have soft tissues greater than the length of a 14G cannula in the 2nd intercostal space mid-clavicular line and this technique may fail to decompress the pneumothorax o Recurrence of tension pneumothorax secondary to obstruction by blood, tissue or kinking Does not facilitate complete (if any) lung re-expansion A large air leak can collect in the pleural space quicker than can be drained by the cannula 3.7.5 Technique 3.7.5.1 Avoid thick muscle, breast tissue or areas with surgical emphysema 3.7.5.2 The 1st choice of site is the 2nd intercostal space in the mid clavicular line using a 14G cannula 3.7.5.3 The cannula should be inserted into the chest attached to a syringe and flushed with 2ml of air if there is no obvious air release on insertion 3.7.5.4 If an anterior approach fails due to suspected depth of chest wall, a lateral approach should be attempted in the 5th intercostal space, anterior to the mid axillary line 3.7.5.5 A thoracostomy is preferred as definitive treatment (see appendix 1) Appendix 1 Authorised staff for this appendix: HEMS CCP + Consultant paramedic X Advanced practitioners approved by ICGG X Doctor X 4 Simple Thoracostomy Without Drain Insertion 4.1 Indications Any pneumothorax in a patient undergoing positive pressure ventilation Actual or near traumatic cardiac arrest Shocked state with chest injuries and no apparent primary cardiovascular cause 4.2 Performing simple thoracostomy: 4.2.1 The incision is usually made with the patient on the floor and with the ipsilateral arm abducted to 90 degrees. Skin incision is performed followed by blunt dissection that should be directed inferiorly over the top of the 4th or 5th rib. 4.2.2 The presence of surgical emphysema and flail segments can make placement of the incision over the 4th or 5th intercostal space difficult. The incision should always be above the nipple line (in males). 4.2.3 Bleeding from the subcutaneous tissues in the axilla would normally be compressed by the drain and sutures. This effect is not present in simple thoracostomy. Blunt dissection can limit the extent of any bleeding. 4.2.4 The hole through intercostal muscles should allow free insertion of a finger without pushing. This may require some of the intercostal muscle being “stripped” off the rib. 4.2.5 Thoracostomy should be performed as soon as possible (i.e. a minute or two) after endotracheal intubation has been secured, if indicated (e.g. simple pneumothorax diagnosed pre-RISK). In a peri-arrest situation needle chest decompression should be considered and bilateral thoracostomies performed while intubation is taking place. 4.2.6 Bilateral thoracostomies should never be performed unless the patient is intubated. 4.3 Technique 4.3.1 With the patient supine abduct the arm to approximately 90 degrees 4.3.2 Clean the skin with chlorhexidine spray 4.3.3 Use sterile gloves 4.3.4 If awake infiltrate the skin, subcutaneous skin and pleura with 1% Lidocaine (max 3mg/Kg) 4.3.5 Make a 5cm incision along the line of the ribs in the 4/5th intercostal space in the mid-axillary line 4.3.6 Use a scalpel for the skin only. Thereafter use blunt dissection to pass through the intercostal muscles and pleura 4.3.7 Make a hole sufficient to push 1 finger into the pleural cavity and finger sweep through 360 degrees. Be careful when you push, as there may be fractures ribs that are sharp. 4.3.8 Confirm the lung is felt up and expanded 4.3.9 Leave the soft tissues to fall back over the wound, which will act as a flap valve 4.3.10 Re-spray the wound with chlorhexidine 4.4 Advantages The lung can be felt / seen to re-expand If the patient persists in a shocked state during transport the thoracostomy can be “refingered” to ensure the lung is up and working thus excluding one cause of obstructive shock Avoids intubation of the chest in a non-clinical area Avoids risk of re-tension caused by blockage and kinking of drainage systems 4.5 Disadvantages Bleeding more likely than needle decompression (reduced with use of blunt dissection) Damage to lung tissue (reduced with use of blunt dissection) Occlusion of thoracostomy during patient packaging (e.g. by patient’s arm) Appendix 2 Authorised staff for this appendix: HEMS CCP + Consultant paramedic X (not autonomously) Advanced practitioners approved by ICGG X Doctor X 5. Thoracotomy 5.1 Introduction 5.1.1 A resuscitative thoracotomy is a surgical incision made usually across the anterior chest wall to allow access to the chest cavity and structures 5.1.2 Patients who suffer a cardiac arrest through penetrating trauma have a universally fatal outcome without surgical intervention.